Provider Demographics
NPI:1861920282
Name:EJIM, JACQUELINE (LCPC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:EJIM
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 PARK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5634
Mailing Address - Country:US
Mailing Address - Phone:443-738-0300
Mailing Address - Fax:443-738-0301
Practice Address - Street 1:1040 PARK AVE STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5634
Practice Address - Country:US
Practice Address - Phone:443-738-0300
Practice Address - Fax:443-738-0301
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7848101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional